11Th Circuit Solicitor S Worthless Check Unit

The State of South Carolina

SOLICITOR’S OFFICE Fifth Judicial Circuit

WORTHLESS CHECK WORKSHEET

1. Check Writer’s Information:

Name: ______SEX___ RACE___

Address: ______City State Zip Code Phone: ______ID or DL#: ______STATE: ____

DOB: ______SSN: ______

2. Date the check was accepted (Can be different than check date): ______

3. Date check deposited (1st deposit date only): ______

4. Bank where check was deposited: ______

5. Deposited within 10 days? YES NO

6. Check was received in Richland County? YES NO

7. Check was received in Kershaw County? YES NO

8. Did you or your agent believe that the check was good at the time of receipt? YES NO

9. Was the check postdated? YES NO

I understand that by signing this form that I attest that there was no agreement to hold the check in question. If I later decide to stop the collection or prosecution process, I will be liable for costs totaling at least $91ºº.

By signing this form, I swear that the above is true.

SIGNATURE: ______DATE:______

PRINT NAME: ______COMPANY: ______

ADDRESS: ______City State Zip Code PHONE: ______E-mail: ______